Lesson 3.3: Dental Charting and Recording Flashcards
A tooth, root, or implant used for support and retention; removable prosthesis
Abutment
Surgical removal of the apex of a root
Apicoectomy
The patient’s most significant symptom or sign
Chief Complaint
Removable replacement of maxillary and/or mandibular teeth
Complete Denture (CD)
Cast restoration covering the anatomical crown
Crown (Gold or Porcelain)
Deciduous Teeth
Primary Teeth; Baby Teeth
Amount of Deciduous Teeth
20 (Max-10/Man-10)
The lateral movement of tooth into space of missing, adjacent tooth; usually mesial movement
Drifted Teeth
Maxillary or mandibular teeth missing in the entire arch
Edentulous Arch
Surgical Removal
Extraction
Outside of the oral cavity
Extra-oral
Abnormal tube-like drainage from abscess to gingival surface
Fistula
Prosthetic teeth attached to natural teeth
Fixed Partial Denture (Bridge)
Cracked tooth
Fractured Tooth
Soft, yellow, corrosive-resistant metal indirect restorations
Gold Restoration
Inside the oral cavity
Intra-oral
Teeth surgically, traumatically, or genetically removed
Missing Teeth
Movement
Mobility
Filled/unfilled resins, glass ionomer, and sealants
Nonmetallic Permanent Restorations
Palpation of the oral cavity, head, and neck for abnormalities
Oral Cancer Screening (OCS)
Motivating patients to change behavior to recognize and prevent dental disease
Oral Health Instruction (OHI)
Artifical tooth in a bridge
Pontic
Thin porcelain fused to the facial surface of a metal crown
Porcelain Fused to Metal (PFM)
Indirect porcelain veneer bonded to a tooth
Porcelain Veneer
The process of withdrawal or wearing away from its normal location
Recession
Tooth filling
Restoration
Types of fillings
- Composite (tooth-colored resin)
2. Amalgam (mercury allow/silver filling)
Snake Eyes
Double Occlusal Pits
Root Canal Filling (RCF) Material
Gutta-percha is placed in canals
Extra Teeth (more than 32)
Supernumerary Teeth
Gutta-percha
A natural polymer prepared from latex from the Percha tree (Palaquium gutta)
Abbreviations Used In Dental Treatment Records:
Amal
Amalgam
Abbreviations Used In Dental Treatment Records:
BWX
Bite-Wing Radiographs
Abbreviations Used In Dental Treatment Records:
B/U
Build-up
Abbreviations Used In Dental Treatment Records:
FPD
Fixed Partial
Abbreviations Used In Dental Treatment Records:
Fl
Fluoride
Abbreviations Used In Dental Treatment Records:
Fx
Fracture
Abbreviations Used In Dental Treatment Records:
HQR
Health Questionnaire Reviewed
Abbreviations Used In Dental Treatment Records:
Hx
History
Abbreviations Used In Dental Treatment Records:
Mand
Mandibular
Abbreviations Used In Dental Treatment Records:
Max
Maxillary
Abbreviations Used In Dental Treatment Records:
Prophy
Prophylaxis
Abbreviations Used In Dental Treatment Records:
RPD
Removal Partial Denture
Abbreviations Used In Dental Treatment Records:
Temp
Temporary
Abbreviations Used In Dental Treatment Records:
Tx
Treatment
Abbreviations Used In Dental Treatment Records:
ZOE
Zinc Oxide and Eugenol
Tooth Decay Classifications:
Small cavity or lesion affecting pits and fissures
Class 1
Tooth Decay Classifications: Extension of class 1 cavity into proximal surfaces of premolars and molars
Class 2
Tooth Decay Classifications: Interproximal surface (mesial and distal) of incisors and canines
Class 3
Tooth Decay Classifications:
Larger surface area, including incisal edge and the interproximal surface of incisors and canines
Class 4
Tooth Decay Classifications: Near CEJ (Cemento-Enamel Junction); a cavity on the cervical third of the facial or lingual surface of a tooth; requires smooth restoration
Class 5
Periodontal Screening and Recording:
Reason behind it
Early detection of periodontal disease
Periodontal Screening and Recording:
The Periodontal probing of sextants
- Max: right to left, then Mand: left to right (standard way)
- Deepest depth scored. Asterisk (*) denotes depth over 10mm
Periodontal Screening and Recording:
PSR Score
No calculus, no bleeding present, and healthy gingiva
Code 0
Periodontal Screening and Recording:
Treatment for Code 0
Appropriate preventive care and possible dental cleaning
Periodontal Screening and Recording:
PSR Score
No calculus and slight bleeding
Code 1
Periodontal Screening and Recording:
Treatment for Code 1
Plaque and calculus removal and OHI
Periodontal Screening and Recording:
PSR Score
Moderate spontaneous bleeding; colored area of probe partly visible in deepest and probing depth
Code 3
Periodontal Screening and Recording:
Treatment for Code 3
Comprehensive perio exam and charting of the affected areas
Periodontal Screening and Recording:
PSR Score
Spontaneous heavy bleeding; colored area of probe not visible
Code 4
Periodontal Screening and Recording:
Treatment for Code 4
Comprehensive perio exam and charting of the affected sextant or full mouth
Periodontal Screening and Recording:
Where to record PSR
Assessment Section of NAVMED/13 (Dental Examination Form)
TRUE OR FALSE:
NAVMED 6600/13 (Dental Examination Form) is a legal document
True
NAVMED 6600/14
Continuation Form
What information is inputted on NAVMED 6600/14
- Patient’s identifying information and treatment date
- Tooth #(s), Medical alert(s), and updated dental class
- All procedures; must be documented with dentist’s signature, printed and DTF stamp
Charting and Recording Miscellaneous Dental Conditions:
Teeth Recommended for extraction
- Two Vertical Lines
2. AKA “railroad tracks”
Charting and Recording Miscellaneous Dental Conditions:
Missing Teeth
- Put “X” on root(s)
2. Not clinically or radiographically visible
Charting and Recording Miscellaneous Dental Conditions:
Partially Erupted
- Clinical Crown Partially Visible
2. Draw an arching line through the long axis of the tooth
Charting and Recording Miscellaneous Dental Conditions:
Edentulous Arch
- Crossing lines each running from the uppermost aspect of one of the third molars to the lowermost aspect of the third molar on the opposite side
- Annual dental exams are required
Charting and Recording Miscellaneous Dental Conditions:
Edentulous Mouth
- Inscribe crossing lines
- One from the maxillary right-third-molar to the mandibular-left-third molar and the other line from the maxillary left-third-molar to the mandibular-right-third molar
Charting and Recording Miscellaneous Dental Conditions:
Removable Partial Denture (RPD)
- Place an “X” over the root of missing tooth/teeth and a horizontal line between teeth and numbers designating the teeth replaced by RPD
- Complete and removable partial dentures
- May be made of metallic compounds
- Improve chewing ability and appearance
Charting and Recording Miscellaneous Dental Conditions:
Fixed Partial Dentures (FPD)
- AKA “Bridge”
2. Outline each (abutments and pontics) and inscribe diagonal parallel lines to indicate gold
Charting and Recording Miscellaneous Dental Conditions:
Porcelain Fused to Metal (PFM)/Fixed Partial Denture (FPD)
Chart identical to composite and note material in remarks section
Charting and Recording Miscellaneous Dental Conditions:
Porcelain Veneer
- Outline Facial Surface
2. Anterior Teeth Only
Charting and Recording Miscellaneous Dental Conditions:
Crown
- Crown Materials
2. Use instead of large restoration
Charting and Recording Miscellaneous Dental Conditions:
Gold Crown
- Outline each aspect of crown
- Draw horizontal lines in the outlined area
- Note material used in remarks section
Charting and Recording Miscellaneous Dental Conditions:
Full Porcelain Crown (FPC)/Porcelain Fused to Metal Crown (PFM)
- Outline each aspect of crown
- Draw diagonal line across cervical lingual portion
- Note materials in remarks section
Charting and Recording Miscellaneous Dental Conditions:
Root Canal Filling (RCF)
- Specialized filling
- Drawing line where root canal(s) would be normally located; from cervical area to apex
- Under filled root canal - vertical line from crown toward apex (showing extent of filling)
Charting and Recording Miscellaneous Dental Conditions:
Temporary Restoration
- Draw an outline of the restoration showing size, location, and shape
- Describe material used the the remarks section
Charting and Recording Dental Anomalies:
Apicoectomy
- Apex surgically removed
2. Draw a triangle on the root pointing away from the tooth
Charting and Recording Dental Anomalies: Deciduous Teeth (Primary Dentition)
- Lettered A - T
2. Circle alphabetical designation on Forensic and Current Status Form
Charting and Recording Dental Anomalies: Supernumerary Teeth (More than 32)
- Outline of tooth location
2. Insert “S” in location on Forensic Chart
Charting and Recording Dental Anomalies:
Drifted Teeth
- Teeth move towards space of an extracted tooth
2. Draw an arrow from number of drifted tooth and arrow point towards drifting direction
Charting and Recording Dental Anomalies:
Retained Root
- Horizontal line on root showing retention level
- “X” missing area
- If extraction is indicated, two parallel lines through the retained tip
Charting and Recording Dental Anomalies:
Fractured Tooth
- Trace jagged fracture line
2. Place in a relative position on the crown or roots affected
Charting and Recording Dental Anomalies:
Root Resorption
- Verify with radiographs
2. Draw a vertical line from the crown toward the apex showing the extent of the filling
Charting and Recording Dental Anomalies:
Periodontitis and Alveolar Resorption
- An estimate of damage is made after a complete clinical and radiographic examination
- Draw a continuous line at the proper level across the roots of the teeth to indicate the extent of gingival recession
- Another continuous line at the level across roots of alveolar resorption
Charting and Recording Dental Anomalies:
Periapical Abscess
- Abscess - open circle for accurate shape and size
2. Outline apex of the root(s)
Charting and Recording a Forensic Examination:
Forensic Examination
- Preprinted on the inside back cover of the dental record
2. Green ink; existing dentition and conditions
Charting and Recording a Forensic Examination:
When is it completed
Completed only once during the military member’s career, usually at accession
Charting and Recording a Forensic Examination:
What happens if a replacement jacket or record is required
A new forensic exam will be completed
Charting and Recording a Forensic Examination:
What is it used for
Identification